BearCreekVilla - Retirement Living on the Park!

Detail Information

I am applying for a position as a:

What is your wage expectation?

Have you ever been convicted of a felony? We will be requiring further documentation due to the nature of the employment.

If Yes, please provide details.

Transportation:Some positions require the team members to provide transportation.

Do you have dependable transportation?

Do you have a valid driver’s license?

Do you have a dependable vehicle?

What distance are you willing to travel to for employment?

Availability

Number of hours you would like to work per week?

Times and days you ARE available to work

Any times NOT available to work

Can you be called at the last minute in case of emergency?

Education

High School

City/Prov

Dates

College/University

City/Prov

Dates

Other

City/Prov

Dates

Degrees/Certificates

Special skills, courses or training that may be relevant to the position

Experience

Discuss any training or experience working with the clients over the age of 65.

What would you like most about working with clients over the age of 65?

Skills

Please indicate whether you have assisted with or performed the following tasks.

Housekeeping YES NO

Vacuuming YES NO

Laundry YES NO

Bathing/ dressing YES NO

Dusting YES NO

Grocery shopping YES NO

Personal Grooming YES NO

Clean bathrooms YES NO

Cooking YES NO

Nursing Services YES NO

Recreation Services YES NO

Driving YES NO

Foot Care YES NO

Bed linen changes YES NO

Medication reminders YES NO

Customer Service YES NO

Telephone Answering YES NO

Computer YES NO

Companion-ship YES NO

Food Service Preparation YES NO

Food Serving YES NO

Marketing YES NO

Home Care YES NO

Senior Care Software YES NO

Concierge YES NO

Facility Maintenance YES NO

Computer Training YES NO

Employment History

Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional space is required.

May we contact your current employer?

Company

from

Job Title

Reason left

Duties

Supervisor

Phone

Company

from

Job Title

Reason left

Duties

Supervisor

Phone

Company

from

Job Title

Reason left

Duties

Supervisor

Phone

Business References

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Personal References

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Name

Address

Relationship/Years Known

Local Phone #

Certification and Release:

I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Signature

Date

604-599-9057

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Personal Information

Detail Information

Transportation:Some positions require the team members to provide transportation.

Availability

Education

Experience

Skills

Employment History

May we contact your current employer?

Business References

Personal References

Certification and Release:

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